The older population is projected to grow rapidly, and although many seniors wish to remain in their homes for as long as possible, challenges related to affordability, accessibility, and poor linkages to health services may make doing so difficult.

Expanding the supply of aging-friendly housing options, rental assistance, home repairs and modifications, accessible residential design and community planning, as well as improving the links between housing and healthcare, among other strategies, can help seniors age safely, comfortably, and affordably in their homes and communities.

Sean Marlin

As the baby boom generation ages, demographers project significant increases in the proportion of the American population age 65 and older.
The Harvard Joint Center for Housing Studies (JCHS) projects that the
number of U.S. adults age 65 and older will grow from 48 to 79 million over the next two decades. By 2035, JCHS expects that 50 million households — approximately 1 out of every 3 in the United States — will be headed by someone age 65 or older, and the number of people age 80 and older will double to 24 million. The older population will also become more racially and ethnically diverse, with the nonwhite share of this population expected to increase from 22 percent to 31 percent.1 The nation’s existing housing stock — in terms of options, affordability, and accessibility — is ill-suited to meet the housing needs of an increasingly older population that overwhelmingly wishes to age in place. State, local, and federal governments and a range of partnerships among housing and health providers and other stakeholders seek to overcome these housing challenges.

Housing Challenges

Older populations face numerous housing challenges, including those related to affordability, physical accessibility, and access to medical and other services inside and outside the home. Seniors in rural areas encounter additional challenges related to their relative
isolation from neighbors, services, and amenities (see “Housing Challenges of Rural Seniors”).

Affordability. Most seniors own their homes, but the percentage of older
adults who rent is expected to increase slightly from 21 percent in 2015 to 23 percent in 2035.2 Both owners and renters face affordability pressures. Since 1989, the percentage of homeowners carrying mortgage debt has nearly doubled for those age 65 to 74 and almost tripled for those older than 75. Even homeowners who have paid off their mortgages have ongoing maintenance costs and taxes that they may struggle to pay.3 Incomes in retirement typically decline and become fixed, susceptible to erosion by inflation generally and by increased costs
for health care and housing specifically. According to the Bipartisan Policy Center, households 80 and older have a median income of $25,000 annually, and nearly 1 in 4 has an income of $15,000 or less.4 Housing cost burdens — households paying more than 30 percent of their income on housing — are a growing problem, affecting renters as well as homeowners. According to one projection, as many as 6.4 million renters and 11 million homeowners
will be cost burdened by 2035, and of these, 8.6 million will be severely cost burdened, spending more than half of their household income on housing expenses.5 In addition to cost burdens, declining incomes can prevent households
from making necessary home repairs or modifications for aging in
place and can make paying for needed health services more difficult. These economic pressures are compounded by the increasing number of seniors carrying debt into retirement, including mortgage debt.6 Seniors with substantial retirement savings and household wealth will be best able to afford the rent, mortgages, property taxes, home repairs, and modifications needed to
safely age in place.

Bath Housing’s Comfortably Home program offers home modifications such as installing and stabilizing stair railings that enhance resident comfort and safety. Sean Marlin

Historically, a wide gap has existed between the net worths of white and nonwhite households. The expected growth in the nonwhite share of the population may mean that an increasing number of older households will rely heavily on Social Security income and may struggle to age in place or afford assisted living facilities or nursing homes.7

Accessibility. As the population of seniors increases, the number of people with disabilities is also likely to increase, especially among groups with a higher incidence of disabilities than the general population: low-income, minority, and renter households. These individuals will need accessibility modifications to age safely and comfortably in their homes. JCHS projects that by 2035, in 31.2 million households, at least one member will have a disability affecting
mobility, the ability to engage in self-care, or the ability to complete basic household activities. Cases of dementia are also likely to increase, even if the rate of incidence falls.8

The existing housing stock, however, is not well suited to meet the needs of individuals with disabilities. Fewer than 4 percent of U.S. residential units are suitable for people with moderate mobility disabilities, and only about 1 percent of units are wheelchair accessible.9 An estimated 44 percent of households need some type of accessibility modification
to use their homes without difficulty.10 Although the need for modifications is great, such improvements can be costly, and seniors already facing affordability
challenges may postpone these improvements in favor of more urgent home
repairs or health expenses. Survey data indicate that although most seniors want to age in place, they are not focused on accessibility improvements.11 Renters, who experience higher disability rates, have less control than homeowners over potential modifications to their homes and therefore may face even greater challenges to matching accessibility to need.12

Isolation. Many older individuals, particularly those who are no longer able to drive, become socially isolated and have difficulty accessing health providers, services, and community amenities. An estimated 22 percent of nondriving seniors age 85 and older live in a household with no drivers. Routine activities such as grocery shopping and getting a haircut can become daunting. Seniors are also likely to need more health services as they age, and many may find that their transportation options to visit doctors or pick up medications are
inadequate or unaffordable. Disabilities and other medical conditions can complicate mobility; a 2009 survey found that 12 percent of those age 50 to 64, 20 percent of those age 65 to 79, and 41 percent of those age 80 and older have difficulty leaving their home because of
a medical condition.13

Existing Programs

At the federal level, HUD’s Section 202 Supportive Housing for the Elderly program addresses both affordability and the connection between housing and supportive services. Under the program, HUD provides interest-free capital advances to nonprofits to develop housing that offers project-based rental assistance and supportive services for very low-income elderly residents.14 In 2015, the average yearly income of Section 202 residents was $13,238, and 38 percent were considered frail or near frail.15 Although not exclusively for seniors and lacking Section 202’s supportive services, the U.S. Department of Agriculture’s (USDA’s) Section 515 Rural Rental Housing program is an
important source of financial help for rural seniors (see “Housing Challenges of Rural Seniors”).

For homeowners, property tax relief can alleviate affordability pressures. These state and local initiatives may take the form of an outright exemption, a limit, a deduction on the appraised value of the property, or tax credits. Any of these programs may impose eligibility
criteria based on income or age. Aging homeowners might also be helped by reverse mortgages that allow owners to access the equity in their
home, which in many cases is their largest asset, without having to leave it. Most reverse mortgages are insured by the federal government through the Home Equity Conversion Mortgage (HECM) program. Homeowners must be able to pay ongoing maintenance, tax, and insurance costs.16

To accommodate an aging population, many more units at all affordability
levels will need to be made accessible to people with disabilities, both through new construction and retrofitting of the existing housing stock. New construction can be designed for accessibility at the outset or in ways that make future accessibility modifications easy to
complete.17 One way to promote accessibility would be through the broader adoption of universal design principles.18 Universal design incorporates features intended to benefit people of all ages and abilities such as wide doorways, step-free entryways, and lever faucets.19 Many of these features are not usually found in existing housing; therefore, modifications will be needed not only to make housing more accessible but also more safe, comfortable, and user friendly. Such modifications range widely in cost, and many households would need assistance to afford the
more expensive modifications. The residences of long-tenured homeowners
may also need repairs beyond aging-friendly modifications, which can
increase affordability pressures. Tax credits and public loans and grants may help lower-income households make their homes more habitable and more suitable for aging in place.20

HUD’s Section 202 program has been a source of assisted housing for low-income seniors, supporting properties such as Oak Meadows in Visalia, California. Photo courtesy of Christian Church Homes

Medicaid waivers may provide funds for residential modifications to help seniors age safely at home, and HUD’s Title I Home and Property Improvement Loans program insures private lenders for loans to make property repairs and improvements; the insured amount is up to $25,000 for a single-family home and slightly more for manufactured housing on a permanent foundation.21 These programs can help low-income seniors afford modifications that will significantly improve their ability to age in place, such as installing grab bars in a shower and building a wheelchair-accessible entrance.

To better connect housing and health services, HUD is exploring a new model through its Supportive Services Demonstration for Elderly Households in HUD-Assisted Multifamily Housing. Owners of HUD-assisted multifamily developments in the treatment group of this demonstration received grants to aid aging in place; transitions to institutional care; and residents’ housing stability, well-being, health outcomes, and health care utilization. Supportive services must include an onsite Enhanced Service Coordinator and an onsite, part-time wellness nurse. Additional services include fall prevention programs, assistance with medication self-management, mental health programs, and partnerships with local service providers. The demonstration involves randomly assigning properties into treatment and control groups to produce rigorous evidence of the intervention’s effectiveness. The demonstration’s model builds on research evaluating Vermont’s Support and Services at Home (SASH) program.22

The SASH program is a care coordination model that uses housing as a platform for services delivered through an interdisciplinary team of
housing staff and health workers. The team conducts a comprehensive health assessment and develops an individualized living plan for each participant. Frequently cited issues from these individual plans inform the creation of a communitywide healthy living plan. Research shows that established SASH participants (those enrolled before April 2012) experience slower growth in Medicare costs than do members of
a comparison group, although SASH participants have not seen a decrease in hospitalizations or emergency room visits compared with the comparison group.23

Another model that has shown positive results both in terms of health outcomes and cost savings is Community Aging in Place — Advancing Better Living for Elders (CAPABLE). CAPABLE began as a Johns Hopkins research study on the effects of in-home services that modify the home environment and change participants’ behavior to make daily tasks easier. Program director Sarah Szanton has visited homes with crumbling steps, holes in the floors, unstable handrails, and other hazards that pose risks for aging residents, particularly those with mounting medical problems. Relatively simple repairs and modifications such as tightening loose banisters, adding a second banister, or lowering cabinet heights can make a big difference in seniors’ ability to manage daily activities. Through CAPABLE, a team that includes a nurse, an occupational therapist, and a handyman assesses the home environment in consultation with the resident to prioritize interventions that enhance functionality, safety, and independence.
Szanton notes that incorporating residents’ input allows the team to tailor responses to the residents that are both specific and meaningful. Although some home modifications entail modest structural changes, Szanton says that out of 500 homes in Baltimore, no landlord denied a request to make a modification, and some took care of the changes themselves. (In some cases, the owner of the home was a family member of the elderly resident.) After initial funding from the National
Institutes of Health and then from the Center for Medicare and Medicaid
Innovation to implement the program in Baltimore, a combination of local
foundations and other stakeholders have expanded the model to 12 locations.24 Research has found Medicare
cost savings for CAPABLE participants as well as increased confidence and improvements in self-management of health behavior.25 An evaluation of the project found that of 281 adults age 65 and older who were eligible for both Medicaid and Medicare and who had difficulty performing activities of daily living, 75 percent had improved performance of activities after completing the program, and their symptoms of depression also improved.26

The SASH program has shown promise for lowering growth in Medic are costs. Photo courtesy of Cathedral Square Corporation

Siloed funding streams may make implementing cross-sector health and housing interventions such as CAPABLE difficult. Although unable to include the medical aspects of CAPABLE, Bath Housing Authority (BHA) in Maine deployed its professional maintenance staff to conduct safety checks (such as testing smoke alarms and cleaning dryer vents), customized accessibility modifications (such as installing grab bars and railings and replacing faucet control knobs with levers), and minor repairs (such as winterizing homes and fixing stairs) in 56 privately owned homes of low-income unassisted seniors during the pilot phase of its Comfortably Home program. Now with funding from MaineHousing, BHA and four other public housing agencies have made low-cost, high-impact modifications and repairs to 62 homes in the first 6 months of 2017. Through grant funding, BHA will be partnering with Mid Coast–Parkview Health, the local hospital, to incorporate the medical aspects of the CAPABLE model into a portion of the homes it reaches through Comfortably Home. BHA’s experience implementing the program has also changed the way the organization manages its properties; it now pays greater attention to their suitability for an aging assisted population with high rates of disability and significant medical needs.27

Another local-level approach involves community planning and design for an aging population. The American Planning Association (APA) recommends that planners eliminate regulatory barriers such as zoning and building codes that impede community-based housing models designed to connect residents to health services. Planners can also consider the transportation and mobility needs of older residents as aging drivers of private vehicles, as passengers of public transit, and as pedestrians and cyclists. The built environment can also include accessibility, visitability, connectivity, walkability, and universal design components that accommodate older residents. Finally, community-level planning could remove barriers to housing options that may meet seniors’ housing needs such as shared housing and accessory dwelling units.28 (See “Communities
Support Seniors With Aging-Friendly Policies.”) These recommendations generally align with smart growth principles and often benefit people of all ages and abilities. For seniors and others with
limited transportation options, mixed-use development that brings medical services and retail such as grocery stores closer to residences can be especially vital. Community paratransit services may also aid this population.

Practical, community-level models that address seniors’ housing challenges include cohousing, villages, and livable communities. For the most part, these models apply to middle-income seniors and emphasize social contact. Cohousing refers to intentional residential communities with planned common spaces for social activities as well as private residences. Most cohousing communities are multigenerational but present a useful option for older households,
whereas some are intentionally targeted to seniors. Villages are member
organizations that coordinate services such as transportation, social gatherings and outings, and grocery shopping for seniors aging in place. Generally, livable communities are those designed along the lines suggested by APA for aging-friendly planning — having safe
and comfortable infrastructure, service, and housing options for seniors. AARP sponsors a network of more than 100 communities seeking to achieve these standards with support from other organizations such as Smart Growth America.29

Future Directions for Research

HUD’s Office of Policy Development and Research has identified several
areas for future research concerning senior housing in the HUD Research Roadmap: 2017 Update. HUD seeks an assessment of the affordable housing needs of seniors and evidence-based strategies for addressing those needs. The Research Roadmap proposes an examination of existing needs and programs as well as input from experts to develop policy recommendations and assistance models to test. The research would include strategies for “housing production, preservation, financing, assistance, and supportive services integration."30

The Research Roadmap also calls for an assessment of the capital needs of the Section 202 Supportive Housing for the Elderly program, as HUD has previously done for its public housing and HUD-assisted multifamily
housing programs. This study would also explore the potential for using
the Rental Assistance Demonstration to recapitalize properties in need of investment.31

Vermont’s Seniors and Services at Home (SASH) program coordinates care for residents through an interdisciplinary team of housing staff and health workers. Photo courtesy of Cathedral Square Corporation

Because of the lack of accessible housing despite high incidences of disability and the increasing proportion of seniors in the U.S. population, HUD is also interested in researching the accessibility features of its assisted multifamily housing stock as well as the extent and types of disabilities among residents of these
properties. The Research Roadmap proposes using survey data and onsite
inspections to support improved outcomes for residents. Similarly, HUD’s
awareness of the aging U.S. population is informing the agency’s interest in learning more about those living in HUD-assisted nonelderly housing who are likely to age in place, which will allow
HUD to better predict and address this population’s needs.32 Research has shown that HUD-assisted adults have
a greater prevalence of several serious health conditions than both the general adult population and unassisted low-income adults, indicating that meeting the health needs of this population presents an opportunity to make a significant impact.33 The Research Roadmap also identifies the need for research to investigate the effects of state Medicaid waiver programs that allow home- and community-based long-term care services on HUD programs such as Section 202. These waiver programs, which vary by state, can offer help to seniors with disabilities and enhance their ability to age in place.34

Finally, HUD is participating in a partnership
with the Japan Policy Research Institute; Japan’s Ministry of Land, Infrastructure, Transport, and Tourism; Japan’s Urban Renaissance Agency; the Japan Housing Finance Agency, and Ginnie Mae in the U.S.-Japan Housing and Innovation Forum and Aging in Place Research Project. More than a quarter of Japan’s population is age 65 and older, and Japan and the United States face a similar set of demographic
and housing challenges. The partners will explore best practices to support aging in place through housing finance and community development policies.35

Pressing Problems, Promising Strategies

Evidence suggests that innovative models hold promise to improve health outcomes and the ability of seniors to
safely, comfortably, and more affordably age in place. Programs such as SASH and CAPABLE are producing results that enrich seniors’ lives, allowing them to achieve their desired goals. These programs succeed at the local level through collaborative partnerships among healthcare and housing providers, nonprofits, and government entities. Ongoing research, including HUD-directed research, can identify and elevate best practices, refine existing models, and lead to new ideas. The scale of the problems — a lack of affordable housing options that are aging friendly, the mismatch between the number of people with disabilities and availability of accessible housing, and the difficulty of connecting residents to needed health services — remains
daunting and will only intensify as the older population continues to grow. Ensuring that the responses rise to the scope and scale of need will require concerted efforts and investments from the public, private, and nonprofit sectors at all levels. Debora Keller of BHA says that local entities are “doing phenomenal work given the climate
and resources, but there is a catch-up that is needed in terms of resources.” In addition to resources, localities will need approaches that incorporate the new construction of suitable units and the retrofitting of the existing stock to make housing options that will meet seniors’ needs as they age.36